Cognitive and emotional empathy in individuals at clinical high risk of psychosis.

BACKGROUND: Impairments of social cognition are considered core features of schizophrenia and are established predictors of social functioning. However, affective aspects of social cognition including empathy have far less been studied than its cognitive dimensions. The role of empathy in the development of schizophrenia remains largely elusive. METHODS: Emotional and cognitive empathy were investigated in large sample of 120 individuals at Clinical High Risk of Psychosis (CHR-P) and compared with 50 patients with schizophrenia and 50 healthy controls. A behavioral empathy assessment, the Multifaceted Empathy Test, was implemented, and associations of empathy with cognition, social functioning, and symptoms were determined. RESULTS: Our findings demonstrated significant reductions of emotional empathy in individuals at CHR-P, while cognitive empathy appeared intact. Only individuals with schizophrenia showed significantly reduced scores of cognitive empathy compared to healthy controls and individuals at CHR-P. Individuals at CHR-P were characterized by significantly lower scores of emotional empathy and unspecific arousal for both positive and negative affective valences compared to matched healthy controls and patients with schizophrenia. Results also indicated a correlation of lower scores of emotional empathy and arousal with higher scores of prodromal symptoms. CONCLUSION: Findings suggest that the tendency to 'feel with' an interaction partner is reduced in individuals at CHR-P. Altered emotional reactivity may represent an additional, early vulnerability marker, even if cognitive mentalizing is grossly unimpaired in the prodromal stage. Different mechanisms might contribute to reductions of cognitive and emotional empathy in different stages of non-affective psychotic disorders and should be further explored.

Better care for less money: cost-effectiveness of integrated care in multi-episode patients with severe psychosis.

OBJECTIVE: To compare cost-effectiveness of integrated care with therapeutic assertive community treatment (IC-TACT) versus standard care (SC) in multiple-episode psychosis. METHOD: Twelve-month IC-TACT in patients with schizophrenia-spectrum and bipolar I disorders were compared with a historical control group. Primary outcomes were entropy-balanced cost-effectiveness based on mental healthcare costs from a payers' perspective and quality-adjusted life years (QALYs) as a measure of health effects during 12-month follow-up. RESULTS: At baseline, patients in IC-TACT (n = 214) had significantly higher illness severity and lower functioning than SC (n = 56). Over 12 months, IC-TACT had significantly lower days in inpatient (10.3 ± 20.5 vs. 28.2 ± 44.9; P = 0.005) and day-clinic care (2.6 ± 16.7 vs. 16.4 ± 33.7; P = 0.004) and correspondingly lower costs (€-55 084). Within outpatient care, IC-TACT displayed a higher number of treatment contacts (116.3 ± 45.3 vs. 15.6 ± 6.3) and higher related costs (€+1417). Both resulted in lower total costs in IC-TACT (mean difference = €-13 248 ± 2975, P < 0.001). Adjusted incremental QALYs were significantly higher for IC-TACT versus SC (+0.10 ± 0.37, P = 0.05). The probability of cost-effectiveness of IC-TACT was constantly higher than 99%. CONCLUSION: IC-TACT was cost-effective compared with SC. The use of prima facies 'costly' TACT teams is highly recommended to improve outcomes and save total cost for patients with severe psychotic disorders.

Fulminant Essential Thrombocythemia Associated with Acquired Von Willebrand Syndrome and Bleeding Episodes in a 14-year-old Girl.

BACKGROUND: Essential thrombocythemia is a chronic myeloproliferative neoplasm. It is extremely rare in children below 15 years of age with an estimated annual incidence of only 0.09 per million. Usually, clinical symptoms associated with essential thrombocythemia are mild or absent. CASE: Here, we present the case of a 14-year-old female patient fulminantly presenting with acute symptoms comprising visual impairment, palmar and plantar stabbing pain. Blood count revealed massive thrombocytosis of 2373 × 109/L. Bone marrow morphology showed elevated numbers of mature megakaryocytes. Von Willebrand factor activity/antigen ratio was significantly reduced compatible with an acquired Von Willebrand syndrome associated with high platelet counts. Molecular analyses for driver mutations of myeloproliferative neoplasms including JAK2V617F, CALR and MPL were negative. Acute therapy comprising hyperhydration and oxygen supply complemented by acetylsalicylic acid led to amelioration of symptoms. Medication with hydroxycarbamide maintained a significant reduction of platelet counts but had to be reduced or withheld several times due to neutropenia. Repeated bleeding episodes observed in the course were clearly associated with increases in platelet counts above 1200 × 109/L explained by acquired von Willebrand syndrome. Sixteen months after diagnosis, therapy was switched to pegylated interferon and platelet counts could be stabilized without significant side effects.

Early detection and integrated care for adolescents and young adults with psychotic disorders: the ACCESS III study.

OBJECTIVE: The objective of the study was to investigate whether a combined intervention composed of early detection plus integrated care (EDIC) enhances outcomes in patients with early psychosis compared to standard care (SC). METHODS: ACCESS III is a prospective non-randomized historical control design 1-year study examining the efficacy of EDIC (n = 120) vs. SC (n = 105) in patients aged 12-29 years. Primary outcome was the rate of ≥6 months combined symptomatic and functional remission. Additional outcomes comprised the reduction of DUP and course of psychopathology, functioning, quality of life, and satisfaction with care. RESULTS: In observed cases, 48.9% in the EDIC and 15.2% in the SC group reached the primary endpoint. Remission was predicted by EDIC (OR = 6.8, CI: 3.15-14.53, P < 0.001); younger age predicted non-remission (OR = 1.1, CI: 1.01-1.19, P = 0.038). Linear regressions indicated a reduction of DUP in EDIC (P < 0.001), but not in SC (P = 0.41). MMRMs showed significantly larger improvements in PANSS positive (P < 0.001) and GAF (P < 0.01) scores in EDIC vs. SC, and in EDIC over time in CGI-Severity (P < 0.001) and numerically in Q-LES-Q-18 (P = 0.052). CONCLUSIONS: EDIC lead to significantly higher proportions of patients achieving combined remission. Moderating variables included a reduction of DUP and EDIC, offering psychotherapeutic interventions.

[Integrated care for patients with first and multiple episodes of severe psychotic illnesses: 3-year results of the Hamburg model]. / Integrierte Versorgung für erst- und mehrfacherkrankte Patienten mit schweren psychotischen Erkrankungen : 3-Jahres-Ergebnisse des Hamburger Modells.

BACKGROUND: The so-called "Hamburg model" is a designated integrated care model according to § 140 of the Social Code Book (SGB) V for psychosis patients fulfilling the definition of severe mental illness (SMI). OBJECTIVES: Description of the model and evaluation of efficacy of all patients being treated for ≥ 3 years. MATERIALS AND METHODS: Service entry illness status, course of illness, and interventions were assessed within a continuous quality assurance study. One hundred and fifty-eight patients who fulfilled the criterion of being treated for ≥ 3 years were analyzed. RESULTS: At service entry, SMI were among others mirrored by a high level of psychopathology (Brief Psychiatric Rating Scale [BPRS]: 80.3) and severity of illness (Clinical Global Impression Severity [CGI-S]/Clinical Global Impression Bipolar scales [CGI-BP]: 5.8), low functioning level (Global Assessment of Functioning scale [GAF]: 35.9), and high rates of comorbid psychiatric (94.3 %) and somatic (81.6 %) disorders. Only 8 patients (5.1 %) disengaged from the service within the 3-year treatment period. The course of the illness over 3 years showed significant and stable improvements in psychopathology (BPRS: p < 0.001), the severity of illness (CGI-S/CGI-BP: p < 0.001), functioning (GAF: p < 0.001), quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire [Q-LES-Q-18]: p < 0.001), and satisfaction with care (Client Satisfaction Questionnaire [CSQ-8]: 2.0 to 3.3; p = 0.164; nonsignificant because of early improvements). Further, compulsory admissions were reduced and medication adherence in addition to working ability improved (all p < 0.001). Data on interventions showed a continuously high frequency of outpatient interventions over time (on average 112.0 per year), a high percentage of patients in psychotherapy (67 %), and a nearly 90 % reduction in inpatient treatment days from year 1 to year 3. CONCLUSION: Integrated care in severely ill patients with psychotic disorders leads to multidimensional illness improvement and stabilization by offering intensive outpatient care.

[Services for the early recognition of psychoses and bipolar disorders in Germany: inventory survey study]. / Angebote zur Früherkennung von Psychosen und bipolaren Störungen in Deutschland: Bestandsaufnahme.

BACKGROUND: In order to successfully implement early recognition and intervention services in psychiatry, it is crucial to improve the attention to and recognition of severe mental disorders and to establish low threshold services that are available at short notice for diagnostic and treatment procedures. MATERIAL AND METHODS: For this inventory survey study, questionnaires regarding the presence and type of early recognition services for psychoses and bipolar disorders were sent separately to German psychiatric hospitals by mail in September and October 2012. Additionally, an internet search and telephone inquiries as well as an alignment of responses from the two surveys and with network lists from published and ongoing early recognition studies were performed. RESULTS: Response rates in the psychosis and bipolar disorder surveys were 21 % (51/246) and 36 % (91/255), respectively. Three quarters of participating institutions reported at least an interest in creating an early recognition service for psychoses and one half for bipolar disorders. Overall, 26 institutions were identified that already offer early recognition of psychoses and 18 of bipolar disorders. Of these 16 are low threshold early recognition centres with direct access at short notice for first-episode patients and person from at-risk groups and separate specific public relations work. Of these early recognition centres five have a separate and easy to find homepage available; in an additional 15 institutions the specific websites are part of the institutions homepage. CONCLUSION: Despite widespread interest and the increasingly recognized importance of early recognition and intervention services in psychiatry, there is currently no nationwide coverage with early recognition services for severe mental disorders in Germany. Public relations and information activities are not (yet) sufficiently provided to reach affected persons and their environment. Common standards are (still) missing and interdisciplinary models are sparse. To correct these shortcomings, amongst other factors, acquisition of sufficient funding for such services is required.

[Mental health of children, adolescents and young adults--part 1: prevalence, illness persistence, adversities, service use, treatment delay and consequences]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 1: Häufigkeit, Störungspersistenz, Belastungsfaktoren, Service-Inanspruchnahme und Behandlungsverzögerung mit Konsequenzen.

Numerous birth-control studies, epidemiological studies, and observational studies have investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use by children, adolescents and young adults is low, even lower than for adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for a poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the interface of child and adolescent and adult psychiatry. Emerging studies show that these health-care structures are effective and efficient. Part 1 of the present review summarises the current state of mental health in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, and treatment delay with consequences.

[Mental health of children, adolescents and young adults--part 2: burden of illness, deficits of the German health care system and efficacy and effectiveness of early intervention services]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 2: Krankheitslast, Defizite des deutschen Versorgungssystems, Effektivität und Effizienz von "Early Intervention Services"

Numerous birth-control studies, epidemiological studies, and observational studies investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use of children, adolescents and young adults is low, even lower than in adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the border of child and adolescent and adult psychiatry. Emerging studies show that these health care structures are effective and efficient. Part 2 of the present review focuses on illness burden including disability and costs, deficits of the present health care system in Germany, and efficacy and efficiency of early intervention services.

Remitted but still impaired? Symptomatic versus functional remission in patients with schizophrenia.

INTRODUCTION: Studies reported close associations between functional outcome and symptomatic remission as defined by the Remission in Schizophrenia Working Group. This observational study was aimed at the investigation of deficits in daily functioning, symptoms and subjective well-being in remitted and non-remitted patients with schizophrenia. METHODS: Symptoms (PANSS), functional outcome (FROGS, GAF), subjective well-being (SWN-K) and other characteristics were assessed in 131 patients with schizophrenia (DSM-IV) within the European Group on Functional Outcomes and Remission in Schizophrenia (EGOFORS) project. RESULTS: A significant better level of functioning was measured for remitted versus non-remitted patients, though remitted patients still showed areas with an inadequate level of functioning. Functional deficits were most often seen in social relations (40%), work (29%) and daily life activities (17%). Best functioning was assessed for self-care, self-control, health management and medical treatment. A moderate to severe level of disorganization and emotional distress was observed in 38% and impaired subjective well-being in 29% of patients defined as being in symptomatic remission. DISCUSSION: The results confirm a close association between symptomatic remission and functional outcome. However, deficits in different areas of functioning, symptoms and well-being underline the need for combined outcome criteria for patients with schizophrenia.

Remission as perceived by people with schizophrenia, family members and psychiatrists.

INTRODUCTION: Studies indicate that patient-rated outcomes and symptomatic remission as defined by the remission in schizophrenia working group rely on different assumptions. The aim of this observational study was to assess symptomatic remission by patients with schizophrenia, family members and psychiatrists and to compare their assessments with standardized criteria and clinical measures. METHODS: One hundred and thirty-one patients with schizophrenia (DSM-IV), family members and psychiatrists assessed remission within the European Group on Functional Outcomes and Remission in Schizophrenia (EGOFORS) project. Symptoms (Positive and Negative Syndrome Scale [PANSS]), functional outcome (Functional Recovery Scale in Schizophrenia [FROGS]), subjective well-being (SWN-K) and demographic characteristics were investigated. RESULTS: Remission assessed by psychiatrists showed the best accordance with standardized remission (80%), followed by remission assessed by family members (52%) and patients (43%). Only in 18%, patients, relatives and psychiatrists agreed in their assessments. Good subjective well-being was most important for remission estimated by patients, good subjective well-being and symptom reduction by family members, and finally better symptom scores, well-being and functioning by psychiatrists. DISCUSSION: Self- and expert-rated clinical outcomes differ markedly, with a preference on the patients' side for subjective outcome. Symptomatic remission as assessed by the standardized criteria plays a secondary role for patients and relatives in daily clinical practice. A more thorough consideration of patients' and caregivers' perspectives should supplement the experts' assessment.

Quality of life profiles and changes in the course of maintenance treatment among 1,015 patients with severe opioid dependence.

INTRODUCTION: Studies indicate that different areas of mental, physical, social and daily life functioning need to be considered in order to improve intervention outcomes in substance user patients. The aim of the study was to assess health-related quality of life (HRQOL) in patients diagnosed with opioid dependence as compared to healthy controls and patients diagnosed with depression and schizophrenia. METHODS: A total of 1,015 outpatients diagnosed with opioid dependence were investigated during 12 months of maintenance treatment. HRQOL (MSQoL), addiction (EUROP-ASI), and sociodemographic characteristics were assessed. RESULTS: HRQOL in opioid dependence improved significantly (p < .001), but was lower as compared to that of healthy controls and patients diagnosed with schizophrenia. HRQOL in opioid dependence comprises addiction-specific aspects, most importantly low material satisfaction, physical health, and social stability. CONCLUSIONS: HRQOL measurement provides valuable information for course and outcome in opioid dependence treatment.

Quality of life under maintenance treatment with heroin versus methadone in patients with opioid dependence.

BACKGROUND: There is increasing evidence that health-related quality of life (HRQOL) is associated with a successful treatment and better outcome in opioid addiction. The aim of the present study was the longitudinal investigation of HRQOL in patients with severe opioid dependence, who were randomly assigned to four groups of medical and psychosocial treatment: heroin (diacetylmorphine) versus methadone and case management (CM) versus psychoeducation (PSE) respectively. METHODS: HRQOL (MSQoL) and physical health (OTI) were investigated in 938 subjects, who participated in the German multi-centre study examining the effects of heroin-assisted treatment in patients with severe opioid dependence. Data for the present analysis were taken from baseline and 12-month follow up. RESULTS: Under both forms of maintenance and psychosocial treatment HRQOL improved significantly during the observation period. HRQOL improvement under maintenance with heroin exceeded improvement under methadone, especially with regard to subjective physical health. HRQOL improvement was significantly associated with better expert-rated physical health. Further analyses showed significant better improvement of HRQOL in subjects treated with PSE compared with CM. CONCLUSIONS: The advantage of heroin with regard to the improvement of HRQOL may be partially explained by a better improvement of physical health under maintenance with heroin compared with methadone, which highlights the importance of a comprehensive model of health care for patients with severe opioid dependence. Future studies need to investigate the benefits of PSE for patients in maintenance therapy.

Early- and delayed antipsychotic response and prediction of outcome in 528 severely impaired patients with schizophrenia treated with amisulpride.

INTRODUCTION: 'Early-onset' studies have shown that symptomatic response often occurs early and that early symptomatic response is predictive for later outcome. Limiting factors of these studies include the restriction on symptomatic outcome, the inclusion of mostly moderately ill patients, and the use of various antipsychotics. METHODS: Response and remission rates were assessed in 528 severely ill patients with schizophrenia at baseline, week 2, 4 and 12 using PANSS, SWN-K, CGI-S, and SOFAS. The clinical measures were combined to one outcome criterion (CombOut). Predicitive validity was analyzed for CombOut using linear regression models. RESULTS: Rate and time to response differed markedly between outcome measures. 32% reached positive symptom response at week 2, 58% at week 4 and 85% at week 12. Non-response at week 4, but not at week 2 was predictive for later non-response. The combined outcome criterion was best predicted by early response in subjective wellbeing (T=-7.88, p<0.001) and social functioning (T=-7.43, p<0.001). DISCUSSION: Rate and time to response might depend on sample characteristics and outcome measure. In severely ill patients early antipsychotic response is possibly delayed from the first 2 to the first 4 weeks. Early response in subjective wellbeing and social functioning are strong predictors for overall outcome, which make them a useful supplementation to the assessment of symptomatic response.

Treatment of severe agitation with olanzapine in 166 patients with schizophrenia, schizoaffective, or bipolar I disorder.

INTRODUCTION: Agitation is a common phenomenon in schizophrenia or acute mania. Because of the inability of patients to give informed consent in such situations, data from consenting studies are limited. METHODS: This observational prospective 5-day study evaluated the effectiveness of olanzapine in a sample of highly agitated patients with aggression. Primary endpoint was mean change of the PANSS-Excited Component (PANSS-EC) score. RESULTS: Mean PANSS-EC score at baseline was 25.5 points, 60.2% were severely agitated and 41.6% severely aggressive. A significant decrease in PANSS-EC total score (-13.3 points) was observed with rapid dose escalation and an average daily dose of 21.2 mg/day of olanzapine. 40 patients (24.1%) required treatment with another antipsychotic and 21 patients (12.7%) were not treated with olanzapine at day 5. At endpoint, 64.2% of patients were in remission of agitation. PANSS-EC reduction was not significantly different in patients with or without concurrent benzodiazepine use. DISCUSSION: Severe agitation with aggression may be well controlled with olanzapine in many cases, possibly by higher initial and overall doses of olanzapine. Controlled studies are needed to confirm these findings.

Rates and predictors of remission and recovery during 3 years in 392 never-treated patients with schizophrenia.

OBJECTIVE: Few studies have prospectively examined remission and recovery as well as their predictors in schizophrenia simultaneously. Aims of the study were to identify remission and recovery rates as well as their predictors in schizophrenia. METHOD: 392 never-treated patients with schizophrenia were assessed over 3 years. Combined remission and recovery required concurrent achievement of symptomatic and functional remission as well as adequate quality of life for at least 6 and 24 months respectively. Predictors were analysed using stepwise logistic regression models. RESULTS: At 3 years, remission rates for symptoms, functioning and subjective wellbeing were 60.3%, 45.4% and 57.0%; recovery rates were 51.7%, 35.0% and 44.3%. Of those, 28.1% were in combined remission and 17.1% in combined recovery. Predictors mainly included the baseline functional status and early remission within the first 3 months. CONCLUSION: The proportion of patients who met combined remission or recovery criteria is low. Early treatment adaptations in case of early non-remission are mandatory.

Association of personality disorders, family conflicts and treatment with quality of life in opiate addiction.

AIM: The purpose of this study was to investigate the association of the current status and longitudinal changes in different clinical and social variables with quality of life (QOL) in opiate addiction. Our hypotheses were that drug use, comorbid personality disorders and social problems are associated with worse QOL. METHODS: 107 participants with long-term opiate addiction were included and interviewed at entry with the Europ-ASI and the PDQ-R. QOL (SF-36) and changes in different domains of the Europ-ASI were assessed after 2 years. RESULTS: Personality disorders, interpersonal conflicts with the family or partner and ongoing need for somatic and psychiatric treatment were significantly associated with worse subjective QOL, whereas changes in drug and alcohol use, the economic situation, legal problems and social problems with persons outside of the family showed no relevant association with QOL. CONCLUSION: Our results provide support for an emphasis in treatment on helping clients to reduce intra- and interpersonal conflicts according to comorbid conditions and among family members and partnerships. In addition, the present data provide further support for the advantages of extended interventions in long-term opiate addiction.